Health Risk Behavior Survey (middle school)

OMB No: ???: Exp Date: ???

Health Risk Behavior Survey

HEALTH AND HEALTH RISK BEHAVIOR QUESTIONNAIRE: PARENT High School Version TABLE OF CONTENTS General Information 1 Injury 2 Rule Breaking 3 Tobacco/Alcohol/Drug Use 4 Physical Activity 6 Dietary Behavior 8 Prevention Behavior 8 Sleep Behavior 9 School Performance 9 Communication 10

I. General Information 1. How tall is your child without shoes on (in feet and inches)? feet inches 2. When was this measurement taken? month day year 3. How much does your child weigh without shoes on (in pounds)? pounds 4. When was this measurement taken? month day year 5. Relative to other children, do you consider your child overweight? Yes No 6. Relative to other children, do you consider your child underweight? Yes No

Public reporting burden of this collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0584).

II. Injury The following questions ask about significant injuries that your child experienced in the past year. Injuries should be included if they required medical attention, resulted in limitations in the child’s day-to-day activities (including play), or that the child considered bothersome for more than a day. Examples of such injuries include a broken bone or a cut that required stitches. 7 . How many times was your child injured in the past 12 months? 8. In the past twelve months, has your child suffered any of the following injuries? (Fill in all that apply). A. An injury related to a recreational activity (for example, while playing on a bicycle or skateboard)? Yes No B. A burn or scald? Yes No C. A broken or fractured bone? Yes No D. An animal bite? Yes No E. A poison related injury? Yes No F. A cut or pierce that required stitches? Yes No

G. An injury caused by a piece of machinery? Yes No 9. How often does your child refuse to wear a seat belt when riding in a car? Never Rarely Sometimes Most of the time Always 10. How often does your child cross the street or run out into the street without checking for cars? Never Rarely Sometimes Most of the time Always 11. How often does your child do dangerous things like jumping off high places? Never Rarely Sometimes Most of the time Always 12. When your child rides a bicycle, how often does he/she wear a helmet? He/she does not ride a bicycle Never Rarely Sometimes Most of the time Always

13. When your child roller blades or rides a skateboard, how often does he/she wear protective gear such as a helmet, wrist guards, or knee pads? He/she does not roller blade or ride a skateboard Never Rarely Sometimes Most of the time Always 14. In the past 12 months, have you been called into school because your child was caught carrying a weapon, such as a gun, knife, or club? Yes No 15. During the past 12 months, how many times was your child in a physical fight? 0 times 1 time 2 or 3 times 4 or 5 times 6 or 7 times 8 or 9 times 10 or 11 times 12 or more times 16. During the past 12 months, how many times was your child in a physical fight in which he/she was injured and had to be treated by a doctor or nurse? 0 times 1 time 2 or 3 times 4 or 5 times 6 or more times

17. During the past 12 months, how many times was your child in a physical fight on school property? 0 times 1 time 2 or 3 times 4 or 5 times 6 or 7 times 8 or 9 times 10 or 11 times 12 or more times 18. To the best of your knowledge, has your child ever tried to intentionally hurt him or herself? Yes No III. Rule Breaking 19. When was the last time your child stole something worth more than $50? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 20. When was the last time your child was required to appear in court for something he/she had done? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never

21. When was the last time your child was sent to the principal or counselor for disciplinary reasons? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 22. When was the last time you child was fired from a job? Within the past month Between 1 month and 6 months ago Between 6 months and 1 year ago Over 1 year ago Never 23. If your child takes prescription medication for ADHD (attention deficit/hyperactivity disorder): In the past 12 months, did he/she ever give or sell his/her medication to others? Yes No My child does not take medication for ADHD IV. Tobacco/Alcohol/Drug Use 24. To the best of your knowledge, has your child ever tried cigarette smoking, even one or two puffs? Yes No

25. To the best of your knowledge, how old was your child when he/she smoked a whole cigarette for the first time? He/she has never smoked a whole cigarette 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older 26. To the best of your knowledge, does your child currently smoke on a regular basis (at least once per week)? Yes No 27. To the best of your knowledge, has your child ever used chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen? Yes No The next 5 questions ask about drinking alcohol. This includes drinking beer, wine, wine coolers, and liquor such as rum, gin, vodka, or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes. 28. To the best of your knowledge, has your child ever had a drink of alcohol other than a few sips? Yes No

29. How old was your child when he/she had his/her first drink of alcohol other than a few sips? My child has never had a drink of alcohol other than a few sips 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older 30. During the past 30 days, on how many days did your child have at least one drink of alcohol? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days 31. During the past 30 days, on how many days did your child have 5 or more drinks of alcohol in a row, that is, within a couple of hours? 0 days 1 day 2 days 3-5 days 6-9 days 10-19 days 20 or more days The next 2 questions ask about marijuana use. Marijuana is also called grass or pot. 32. To the best or your knowledge, has your child ever used marijuana? Yes No

33. How old was your child when he/she tried marijuana for the first time? My child has never tried marijuana 8 years old or younger 9 or 10 years old 11 or 12 years old 13 or 14 years old 15 or 16 years old 17 years old or older The next 3 questions ask about other drugs. 34. To the best of your knowledge, has your child ever sniffed glue, or breathed the contents of spray cans, or inhaled any paint or sprays to get high? Yes No 35. To the best of your knowledge, has your child ever used any drugs, including illegal drugs, to get high? Yes No 36. During the past 12 months, has anyone offered, sold, or given your child an illegal drug on school property? Yes No The next 3 questions ask about sexual behavior. 37. To the best of your knowledge, has your child ever had sexual intercourse? Yes No 38. To the best of your knowledge, is your child sexually active? Yes No

39. How many times has your child been pregnant or gotten someone pregnant? My child has never had sexual intercourse 0 times 1 time 2 or more times V. Physical Activity 40. On how many of the past 7 days did your child exercise or participate in physical activity for at least 20 minutes that made him/her sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 41. On how many of the past 7 days did your child exercise or participate in physical activity for at least 20 minutes that did not make him/her sweat and breathe hard, such as fast walking, slow bicycling, skating, pushing a lawn mower, or mopping floors? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

42. On how many of the past 7 days did your child do exercises to strengthen or tone his/her muscles, such as push-ups, sit-ups, or weight lifting? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 43. On an average school day, how many hours does your child usually spend reading for pleasure (books/magazines/newspapers)? My child does not read for pleasure on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 44. Do you limit the amount of time that your child spends watching television? Yes No 45. On an average school day, how many hours does your child watch TV or DVD/videos? My child does not watch TV on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day

46. On an average school day, how many hours does your child listen to music (radio, tapes, CDs, MP3s)? My child does not listen to music on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 47. On an average school day, how many hours does your child play with video or handheld games? My child does not play with video games on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 48. On an average school day, how many hours does your child use a computer for something that is not school work? My child does not use a computer for something that is not school work on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day

49. On an average school day, how many hours does your child use more than one type of media at the same time (like music and computer, or TV and reading)? My child does not use more than one type of media at the same time on an average school day Less than 1 hour per day 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day 50. Do you use internet filters or other methods of parental supervision when your child is on the Internet or watching television? Yes No 51. Does your child have access to R-rated movies and videos or mature rated video games? Yes No 52. Are there family rules about what TV programs your child is allowed to watch? Yes No 53. In an average week when your child is in school, on how many days does your child go to physical education (PE) classes? 0 days 1 day 2 days 3 days 4 days 5 days

54. How often does your child participate in organized or team sports? My child does not participate in organized sports Daily Twice a week Weekly Every other week Once a month Less than once a month 55. Relative to other children his/her age, do you consider your child: Much more active than other children Somewhat more active than other children About as active as other children Less active than other children Much less active than other children VI. Dietary Behavior 56. During the past 7 days, how many times did your family eat a meal together? Never Once Twice 3 times 4 times 5 times 6 times 7 or more times 57. Is your child on a special diet? My child is not on a special diet Feingold diet Lactose-restricted Sugar-restricted Oligoantigenic Other (Specify): ______________________

VII. Prevention Behavior 58. How often does your child brush his/her teeth? Daily 5-6 days a week 3-4 days a week 1-2 days a week Less than once per week Never 59. About how long has it been since anyone in the family last saw or talked to a doctor or other health care professional about your child’s health? 6 months ago or less More than 6 months, but not more than 1 year ago More than 1 year, but not more than 3 years ago More than 3 years ago Never 60. When was the last time your child saw a doctor or nurse for a check-up or physical exam when he/she was not sick or injured? 6 months ago or less More than 6 months, but not more than 1 year ago More than 1 year, but not more than 3 years ago More than 3 years ago Never 61. During the past 12 months, how many times has your child gone to a hospital emergency room about his/her health? None 1 time 2-3 times 4-9 times 10-12 times 13 or more times

62. During the past 12 months, have you seen or talked to a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker about your child’s health? Yes No 63. During the past 12 months, have you seen or talked to a minister or member of the clergy about your child’s health? Yes No 64. During the past 12 months, have you seen or talked to a chiropractor about your child’s health? Yes No 65. During the past 12 months, have you seen or talked to a physical therapist, speech therapist, respiratory therapist, audiologist, or occupational therapist about your child’s health? Yes No VIII. Sleep Behavior 66. On an average night, does your child have difficulty sleeping? Yes No 67. Does your child snore? Yes No 68. Is your child a restless sleeper? Yes No 69. Does your child awaken during the night? Yes No

70. How many hours of sleep does your child get on an average night? More than 8 hours 6-8 hours 4-5 hours Less than 4 hours 71. Is your child sleepy during the day? Yes No IX. School Performance/ Stressful Events 72. Has a representative from a school or a health professional ever told you that your child has a learning disability? Yes No 73. Do you consider your child an: A student B student C student D student F student 74. Do you have concerns about your child’s current and future school performance? Yes No 75. During the last year, did your child get poor grades? Yes No 76. During the last year, did your child get in trouble with a teacher or principal at school? Yes No

77. During the last year, did your family move to a new home or apartment? Yes No 78. During the last year, has your family had a new baby come into the family? Yes No 79. During the last year, has anyone moved out of your home? Yes No 80. During the last year, did a family member die? Yes No 81. During the last year, did another relative or friend who was close to your child die? Yes No 82. During the last year, has a family member become seriously ill, injured badly, and/or had to stay at the hospital? Yes No 83. During the last year, has someone else your child knows, other than a member of your family, been beaten, attacked, or really hurt by others? Yes No 84. During the last year, has your child been afraid to go outside and play, or have you made your child stay inside because of gangs or drugs in your neighborhood? Yes No

84. During the last year, has your child had to hide someplace because of shootings in your neighborhood? Yes No X. Communication 86. How much have you spoken to your child about not smoking? Not at all Some A moderate amount A great deal 87. How much have you spoken to your child about not drinking? Not at all Some A moderate amount A great deal 88. How much have you spoken to your child about not using drugs? Not at all Some A moderate amount A great deal 89. How much have you spoken to your child about birth control? Not at all Some A moderate amount A great deal 90. How much have you spoken to your child about sexually transmitted diseases? Not at all Some A moderate amount A great deal

FOR STUDY USE ONLY
Date Interviewed	Month Day Year	Interviewed by